5-7 SUMMER ST - BUILDING INSPECTION PLdfM I MIK f L454M APPROVED BY 1W
IWZCMB PROR TD A PERMIT BEING GRANTED
C CITY OF_SALEM
No. J ) Oft—ALL
j,
Wad 3
zonkq ota m
IM Fohc MY Dkift7� Ya No ideati Locatlason ofIs Propaiy LoceMtl in
r nN Cw8w4abon AmW Yak_No
Permit to:
BUILDING PERMIT APPUCA71ON FOR:
(Circle whichever apply) Roof, Rercof, Instal Siding, Construct Deck, Shed, Pool,
(!�Aeplace. Other
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS BI PROCESSING
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accordc1ig.to the following
Owners Name Ic...l--r
Address A Phone is. 9b
Architect's Name
Address d Phone ( )
Mechanics Name
Address 6 Phone 1 ( I
What is the pupm it bunaW --
mftm or buldnp4 g 1 1C lL n a dw�anp.for how many r
Wo b fi ft om".. to kw? Meat,?
E«t«m.a oo�t 12- MY U� « Zl�t!? WAU « `{13
of Applicant
SIGNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: tN
f
SJNI011t18 � liOlO3 '
O�AOklddl/
03LNVMD W d
NOLLVOOI
CIL MUM
dOd NOLLvonddv
//} �I
onwnv 1YW6it/{ fi� G�1ftC/YYfsae
boo w. ,.S1,.j
1cue.as Sadao. N/assos" 0.2111
Workers' Compensadn Imotance Affidawk
. . Wid►.s p>indpsi pfap of btoGwa an
do hereby'cersty under t)w paias and patiMes of pa*y, tloo
i ant as employer providing wwkws' compenwtloo coverage for cry employees workbg on '
di job.
Insurance rotas Pe Nunsbw
�I am a sole proprieso►and have no one working fdr an In mW apadgre
(Y 1 am a sole proprietor, general concraesor or homeowner (drde oee) and have Mrad the
contractors lined below who-have the fo workers'Ikawiri «antperas,+tlott pe8dess •
?ems (I �c
Coeaaaor Inwnnre Com�stry/!•o Number
IZ4
Coauer Insurance Cornpatry/*o N
Contractor Insurance Company/Polity NuMbw
0 1 am a Cow-nei, performing all the work ngself.
• r+cwrs"ow a caw J Oi M N le/ were n er Office A Mw'adNws of eM 01A N cowwap cwlkseon one an lien w soon
cowrsp as ceeerco cow Swiss 1 A of MGt 15 1 can kN w ew Wwe Wm of wbeisa sonsda cwmdm of a rasa of a w4 I.SODi00&w r err
resn'iwwn"MMM a-tiA� in she i m of s STOP WORK ORDER aoe s Gw d S 100AO s sw stsiec sr.
line ' day of
.iccr 'F iLkee u a g Departs nt
ensing Ecare
Selectmen Office
ricslch Depsrrncr-
_. - - _ . - .eeCC A: : = eye 40e 40e T]e
ruw�c �worortr .
WARM% OMI r PLO"
' wasp rwo�r5e
IPMM
ite1► 1 - -
I�OYIC; AL.
11A�
. f •
D�AL��AtlmAV1!
• 5�eesireswl�rparWar dlQ,s/q Off= nro�srL�rt si ssoailhs
d r re• i/id��wl�rereo■�iellaaa—dir
4wt dY apeep�r
• �s�t �11�11�L sn�p� ���'
l� M
Dow
lfALT oas�irl�r�swly WMIAM
QLL1al�frCLA�L?)
��QO►asrr
'1�s�bow s�ls�rt aiw Sas rdwo�da���,nbr orsir •
diowndudmhgdrmkwmmbodkposdimspo,p lit
S�►r ddorl6�►11�'t,ems.tiJ�i/rba0ar 1fe�wr400d
isdesti`s Iealloa dr�ti